Despite a dip in the numbers in 2020, San Diego health experts expect rates of sexually transmitted diseases to continue climbing to historically high levels — and marginalized groups, such as people of color and members of LGBTQ communities, are hit the hardest.
Bacterial STDs have been on a concerning rise for years. In the past two decades, the rate of chlamydia in San Diego County more than doubled. Gonorrhea tripled. And the rate of syphilis in 2020 was more than 50 times what it was in 2000.
Social distancing measures implemented in the early part of the pandemic may have contributed to a drop in those rates in 2020, but the county official managing STD public health strategy warns that the recent data likely doesn’t indicate a downturn.
“I don't think that's indicative of the long-term trends that we can expect,” said Dr. Winston Tilghman, STD controller for the county. “At the local level, as well as at the state and national levels, we're seeing historically high cases and rates of these bacterial sexually transmitted infections.”
While the pandemic disrupted society in ways that reduced the spread of STDs, experts said it probably also curbed testing. Health care facilities limited outpatient services, and patients may have been hesitant to risk coronavirus exposure for an STD test.
With limited routine testing, asymptomatic STDs may have gone undetected, Tilghman said, and some infections were likely treated based on patients’ symptoms without a positive test.
Tilghman noted that STD rates had already started to rise again toward the end of 2020.
“We are likely going to see similar trends to what we were seeing pre-COVID,” he said.
While many STDs can be prevented and cured, the growing rates in the region pose a public health risk. Infections that are not caught and treated early can result in life-long or fatal consequences. Plus, gonorrhea has become harder to treat as it grows resistant to antibiotics.
“There are emerging issues and so they should be taken seriously,” Tilghman said.
Disproportionate effects
Sexually transmitted infections don’t affect the population equally. Young people are at greater risk. People of color generally have higher rates of STDs than white people. Men who have sex with men and transgender women are more likely to get infections.
Eric Walsh-Buhi, an adjunct professor at the San Diego State University School of Public Health, said these groups are at greater risk because of social determinants of health.
“Social determinants of health are those things in daily life that help keep you healthy or make you sick,” he explained. “Poverty and substance abuse, addictions, lack of access to health care, health insurance, as well as things like housing and housing discrimination.”
Social networks can play a huge role in sexual health, Walsh-Buhi added, so the rates also vary greatly by geography. For instance, South Bay has a much higher prevalence of chlamydia than East County.
Walsh-Buhi also ran a CDC-funded research project in South Bay that recruited Latino youth to perform a community needs assessment. That group eventually started a digital media campaign to raise awareness of sexual health issues in their community.
“These are clearly cultural and geographic communities,” Walsh-Buhi said. “If the STD rate is high in that community, then any one individual in that community is more likely to become infected with an STD.”
More money, fewer STDs?
San Diego’s long-term growth in STD rates follows a national trend. New data released this week from the Centers for Disease Control and Prevention shows that while chlamydia declined in 2020, other STDs like gonorrhea and syphilis rates continued to climb.
The explosion in cases across the U.S. occurred while STD prevention funding grew weaker, according to the National Coalition of STD Directors, and research shows that this kind of funding is linked to lower infection rates.
Given the rising STD rates, Walsh-Buhi called for more public health funding.
“You're not going to see things like a syphilis walk or a gonorrhea walk,” he said. “Another thing we need to be fighting is that stigma of even talking about it and making it a public health priority.”
San Diego County has seen an influx of funding in recent years to combat STDs. From 2016 to 2021, funding distributed by the state to the county increased from $508,000 to $1.1 million per year. And in 2016, the state enacted the California Healthy Youth Act aimed at providing kids with “comprehensive sexual health education and HIV prevention education.”
But so far, it’s unclear how these changes will affect the region’s STD rates, Tilghman said.
Meanwhile, treating these illnesses — bacterial STDs, as well as viral STDs such as HIV, herpes and human papillomavirus — costs billions of dollars annually in the U.S.
HIV rates persists among people of color
Unlike most other STDs, the number of new HIV infections in San Diego County has been on a downward trend for many years.
“You get a drop and then it levels off for a few years and then you get another drop,” said Samantha Tweeten, an HIV epidemiologist for San Diego County.
Tweeten attributed a sharp decline in new HIV cases in 2020 to the pandemic.
“I just don't think that people were getting tested,” she said, adding that a preliminary count for 2021 indicates that the number of new cases had jumped to about 400, similar to figures seen before the pandemic.
“The lower incidence — the number of annual new HIV infections — may have to do with actual prevention strategies and perhaps more awareness,” said Dr. Gabriel Wagner, an infectious disease specialist at UC San Diego Health. “However, among some groups, the incidence is still holding steady.”
As with bacterial STDs, certain populations are at higher risk — younger men, particularly those who have sex with men, along with Black and Hispanic people and transgender women.
In the last five years, the rate of new HIV diagnoses among Hispanic people in San Diego County was more than twice that of white people. The rate for Black people was 3.8 times as high.
Wagner stressed the importance of testing and prevention for curbing HIV infections. People at high risk can use pre-exposure prophylaxis, or PrEP, a medication taken daily to reduce the risk of contracting HIV. Condoms are also highly effective at preventing the spread of the virus and other STDs.
But gaps remain. As of 2019, only about a quarter of people who needed PrEP were actually on it, according to data put out by the U.S. Department of Health & Human Services. And data suggests that many people are not taking medications to suppress their viral load, which can prevent both the spread of the virus and complications from HIV infection.
“Unfortunately, the groups that I mentioned earlier, such as Latinx men who have sex with men, oftentimes do not have availability are at easy access to such a testing and prevention services,” Wagner said. “That can also contribute to disparities and high rates of both HIV and STIs.”
Research shows that stigma can cause people to delay treatment or avoid testing and prevention methods such as PrEP.
Wagner recalled a Spanish-speaking patient he first saw in 2018, who after years of HIV infection, began having complications.
“Several years back, someone had told him of the diagnosis, but he had decided to put it out of his mind,” he said. Wagner believes the stigma associated with HIV, along with a lack of culturally sensitive care, prevented the patient from addressing the problem when he first encountered it. “Things got really bad and he had to be hospitalized.”
Wagner, who identifies as Hispanic and is a native Spanish speaker, said he was able to talk to the man and start treating his infection.
“Part of the reason that perhaps he had not connected with the health care system is because he didn't find a Spanish speaker,” Wagner said. “He found one with me and he now has excellent control of his HIV infection and is doing very well.”
